Analysis Forensic Investigation When the hold was opened after the fire, an assessment showed that the wood bundles in the vicinity of the welding work had been destroyed by a smoldering, slow-burning yet intense fire. Burn patterns indicated that the fire originated from beneath the top bundles and inboard from the first row of bundles along the port side. Bundles were systematically lifted out of the cargo hold in an effort to determine the seat and cause of the fire. After four tiers of bundles were removed, burn patterns suggested that the seat of the fire had been near the gap between the first and second rows on the port side, four tiers down from the top (see Figure2 and Photo3). Carbonized wood and ashes were examined in that vicinity, but no indications were found as to the source of ignition. Figure2. Cross-section view (not to scale) Before the cargo was disturbed, cigarette butts and an empty cigarette package were found on top of the wood bundles near amidships. Smoking was forbidden in the hold. Ignition sources were present within the hold of the Skalva, which had been loaded with a combustible cargo of dry softwood lumber. The void space between the bundles that were inboard of the first row and adjacent to the hatch coaming was not blocked, and fire-retardant blankets were not used to cover the bulk wood cargo nearby. Both smoking and welding in the hold considerably increased the risk of fire. However, given the sequence of events, the proximity of the welding work to the fire zone origin, as well as the zone's depth (four bundle tiers down), there is a high probability that hot welding by-products ignited the fire. Hot Work Permit and Assessing Fire Risks Whenever hot work such as cutting or welding is performed on board a ship, it introduces fire hazards to the surrounding areas. Good shipboard practices and many port procedures, such as those at Gasp, call for a hot work permit to be issued before the start of such work. Typically, a permit provides a step-by-step checklist for hot work fire-prevention responsibilities and procedures before, during, and after such work is conducted. An assessment of the fire risks is carried out in advance, and appropriate steps are taken to minimize those risks before the hot work begins. Although the Port of Gasp issues hot work permits, these are issued solely as an acknowledgement that the relevant port official is aware that the work is being carried out and that the operation does not pose an unacceptable risk to other activities scheduled at or near the port facility. The actual assessment of the fire risks on the particular vessel requesting the permit is left to the contracting parties, such as the master and/or contractor. Some larger Canadian ports, such as the Port of Montral, Quebec, ensure that an assessment of each work site is undertaken by fire-prevention specialists employed by the port before the issuance of any permit. Under the ISM Code, the Skalva had a procedure for reducing risks whenever welding work was being undertaken. Although well-intentioned, this procedure was quite general and did not provide comprehensive guidance. Consequently, risks associated with welding were not fully assessed, and instituted safety measures were inadequate. Without the benefit of a comprehensive risk assessment, the hazards associated with hot work may go unnoticed and fire-prevention measures may be inadequate. In this occurrence, the guarding used to confine the spills and slag and protect the wood cargo was insufficient. Additionally, no dedicated fire watch was maintained. Although it is not the practice at the Port of Gasp to use the services of fire-prevention specialists before issuing a hot work permit, fire-risk assessment by a competent specialist could help mitigate some of the risk. Furthermore, the vessel's hot work procedures did not fully achieve the intended aim, that of reducing risk when welding work is being undertaken. To be effective, procedures must be specific and comprehensive. Port and City Emergency Procedures and Response In this occurrence, both the city and the port had emergency procedures in place at the time of the fire. Although the city's emergency response plan contains detailed information on managing emergencies, no specific risk analysis or corresponding standard response scenarios have been established for an emergency at the port, nor for any other specific emergency. In some instances, a city service such as the fire department may be needed at the port for an on board emergency. It is also conceivable that an emergency at the port could affect the nearby city of Gasp, subjecting the population to undue risk. For these reasons, the port ought to be included as an area of interest for a specific risk analysis in the city's emergency response plan. On the other hand, the port's emergency procedures contain various scenarios and specifically list the city's fire department as an agency to call in the event of a vessel fire. However, with no specific person allocated to this task - the scenarios mention only a generic observer - it was not until some 19hours after the Skalva fire was discovered that the city's fire department was informed. In 1997, following an explosion and fire on board the petroleum tanker Petrolab at St.Barbe, Newfoundland, improved emergency preparedness at local ports was called for.8 In1998, the vessel Southgate suffered a fire in the hold while at the Port of Grande-Anse, Quebec.9 Not only were the local municipal firefighters needed, but firefighters from a nearby military base were also called for support. Several lessons were learned following the Southgate fire, including the need to inform local fire departments of developing situations in a timely manner. The Port of Gasp response plan could benefit from these lessons learned. In this instance, the harbour master did not call 911or TCHarbour Operations, and a detailed assessment of the risks posed to the harbour or the community was not carried out during the alert phase of the emergency. Essential, safety-critical, and value-added communications were left to third parties such as the vessel's agent, whose principal interests rest with the vessel and not with the port. Additionally, port and city emergency plans and procedures were neither integrated nor co-referenced. Without an integrated approach, emergency response may be less than optimal. Periodically conducting simulated exercises would provide an opportunity to identify and address shortcomings identified in this investigation. Alert and Warning System (AWS)10 In this occurrence, the local TC inspector was alerted by the ship's agent some 2.5hours after the fire was discovered; it took another 30minutes before the MCTS was alerted. Although the MCTS informed the AWS officer in a timely manner, the interested stakeholders - contrary to accepted procedures - were not promptly notified by telephone but were sent the information by fax. Since this was done near the close of normal business hours, several interested stakeholders only became aware of the fire on the Skalva the following morning. Only the TC Harbour Operations standby officer was called by the MCTS, belatedly, at about 1900 on 04January2006. The quality and the lack of urgency of the now-second-hand information given at this time induced the officer to take no further action. In the first instance, all the initial communications were done by the ship's agent when he became aware of the fire on board the Skalva. The master did not initiate communication with the MCTS when the fire was discovered, nor did the harbour master communicate with the TCHarbour Operations standby officer upon becoming aware of the fire at approximately 1630 (in order to give first-hand, value-added information as was required by the port's emergency procedures). Finally, the local firefighter brigade was not called until 0830the next morning. The importance of timely accident reporting has been underlined in the past,11 and information at hand suggests that, at almost every step of the alert and warning process, the system broke down or did not function in an optimal manner. The interested stakeholders were not readily alerted, although the consequences in this instance do not appear to have been aggravated by this oversight. CO2 Smothering For the fire on the Southgate, the hatches, which had been closed ahead of the release of CO2, were re-opened within 24hours, at which point the fire subsequently re-ignited. This was also noted in the case of the wood-pulp fire on board the VaasaborgM in2001.12 In the case of the Skalva, if not for the advice of the vessel owner's representative, who had experienced the Southgate fire, the hatches may have been opened on 08January2006 without the presence of a backup supply of CO2. Temperature monitoring, as was done in this case, is only one element in the decision-making process to open (or not) the hatches. Time is another critical factor, particularly as temperature readings may be erroneous when carried out at a distance from the seat of the fire. Readings may be affected by cargo and the ship's structure. Given the mass of cargo involved on a typical vessel and the permeability of a stow (such as bundles of wood or other break bulk commodities), past experiences demonstrate that a minimum period in excess of a few days may be necessary to ensure that cargo does not re ignite. In this instance, sufficient time was allowed before opening the hatches. Welding was undertaken in the hold of the Skalva without adequate precautions or protection for the cargo of dry softwood construction lumber. Given the sequence of events, the proximity of the welding work to the fire zone origin, as well as the zone's depth (four bundle tiers down), there is a high probability that hot welding by-products ignited the fire.Findings as to Causes and Contributing Factors Welding was undertaken in the hold of the Skalva without adequate precautions or protection for the cargo of dry softwood construction lumber. Given the sequence of events, the proximity of the welding work to the fire zone origin, as well as the zone's depth (four bundle tiers down), there is a high probability that hot welding by-products ignited the fire. In small Canadian ports, fire-prevention specialists do not always undertake an independent assessment of each work site before a hot work permit is issued for a particular vessel, placing vessels and ports at undue risk. Information concerning the fire on the Skalva was slow to reach all interested stakeholders and precluded a timely and coordinated response. When port and city emergency plans and procedures are not integrated or co-referenced, emergency response may be improvised and less than optimal. Without comprehensive, task-specific procedures that give adequate guidance, the intended aim of a safety management system pursuant to the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code) (that is, reducing risks and making ship operations safer) cannot be fully realized.Findings as to Risk In small Canadian ports, fire-prevention specialists do not always undertake an independent assessment of each work site before a hot work permit is issued for a particular vessel, placing vessels and ports at undue risk. Information concerning the fire on the Skalva was slow to reach all interested stakeholders and precluded a timely and coordinated response. When port and city emergency plans and procedures are not integrated or co-referenced, emergency response may be improvised and less than optimal. Without comprehensive, task-specific procedures that give adequate guidance, the intended aim of a safety management system pursuant to the International Management Code for the Safe Operation of Ships and for Pollution Prevention (ISM Code) (that is, reducing risks and making ship operations safer) cannot be fully realized. The arrival and cargo discharge of the IrvingCanada was delayed until such time as the risks were considered acceptable and additional conditions were imposed on both vessels to permit safe operation. Permitting air to prematurely enter a cargo hold following a fire negates the smothering action of the carbon dioxide (CO2) and can lead to re-ignition. In this occurrence, sufficient time was allowed before the hatches were opened so as to avoid this. The role assumed by the harbour master during the critical alert and warning period did not follow established procedures and best practices.Other Findings The arrival and cargo discharge of the IrvingCanada was delayed until such time as the risks were considered acceptable and additional conditions were imposed on both vessels to permit safe operation. Permitting air to prematurely enter a cargo hold following a fire negates the smothering action of the carbon dioxide (CO2) and can lead to re-ignition. In this occurrence, sufficient time was allowed before the hatches were opened so as to avoid this. The role assumed by the harbour master during the critical alert and warning period did not follow established procedures and best practices. On 05 April 2006, the TSB issued Marine Safety Advisory (MSA)05/06, Adequacy of the Assessment of Fire Risks Associated with Hot Work Undertaken in Canadian Ports, addressed to the Director General, Airport and Port Programs, at Transport Canada (TC). TC responded to MSA 05/06 by stating that port officials issue hot work permits, not to comment on the safety of a particular operation but rather with a view to ensuring that such hot work does not pose an unacceptable risk to other activities at or near the port. TC further stated that specific risk assessments on board each vessel are left to trained professionals - without being specific as to whom these trained professionals might be. The issuing of hot work permits was, however, placed on the agenda of the Airport and Port Programs Directorate's May2006 operations seminar and the matter was discussed. In February 2006, Marine Communications and Traffic Services (MCTS), Canadian Coast Guard, Quebec Region, undertook an internal review with operational MCTS officers to ensure that all proper agencies dealing with this type of situation were promptly notified.Safety Action Taken On 05 April 2006, the TSB issued Marine Safety Advisory (MSA)05/06, Adequacy of the Assessment of Fire Risks Associated with Hot Work Undertaken in Canadian Ports, addressed to the Director General, Airport and Port Programs, at Transport Canada (TC). TC responded to MSA 05/06 by stating that port officials issue hot work permits, not to comment on the safety of a particular operation but rather with a view to ensuring that such hot work does not pose an unacceptable risk to other activities at or near the port. TC further stated that specific risk assessments on board each vessel are left to trained professionals - without being specific as to whom these trained professionals might be. The issuing of hot work permits was, however, placed on the agenda of the Airport and Port Programs Directorate's May2006 operations seminar and the matter was discussed. In February 2006, Marine Communications and Traffic Services (MCTS), Canadian Coast Guard, Quebec Region, undertook an internal review with operational MCTS officers to ensure that all proper agencies dealing with this type of situation were promptly notified. Safety Concerns Hot Work The Port of Gasp, like many small ports in Canada, issues hot work permits as an acknowledgement that the relevant port official is aware that the work is being carried out and that the operation does not pose an unacceptable risk to other activities scheduled at or near the port facility. The actual assessment of the fire risks on the particular vessel requesting the permit is usually left to the contracting parties, such as the master and/or contractor. Typically, safety precautions are specified in checklists drafted pursuant to the vessel's safety management system. In this occurrence, while the vessel had procedures for reducing risks whenever welding work was being undertaken, they were quite general and did not provide comprehensive guidance. Furthermore, not all of the procedures were followed; for example, there was no dedicated fire watch. Some large Canadian ports, such as the Port of Montral, Quebec, ensure that an assessment of each work site is undertaken by fire-prevention specialists employed by the port before the issuance of any permit. Although it is not the practice at the Port of Gasp to use the services of fire-prevention specialists before issuing a hot work permit, fire-risk assessment by a competent specialist could help mitigate risks associated with hot work on vessels. Fire-prevention specialists are employed by many municipalities and arrangements could easily be made for service sharing. Although this issue was discussed at the Airport and Port Programs Directorate's May 2006 operations seminar, no new measures are known to be forthcoming. Although the TSB database shows that there have been two other occurrences in which hot work operations resulted in a fire,13 the TSB notes that, internationally, hot work operations have resulted in other fires. For example, in 1998,the Liberian passenger vessel Ecstasy had departed the Port of Miami, Florida, with 2565passengers when a fire started in the main laundry. The probable cause of fire was the unauthorized welding by crew members in the main laundry that ignited a large accumulation of lint in the ventilation - the welders did not comply with the hot work permit procedures outlined in the vessel's safety management system manual.14 More recently, a general cargo vessel en route to the United Kingdom with a cargo of plywood in the hold was carrying out hot work operations and molten steel fell into the hold and ignited the plywood stowed below. No fire watch was established, no hot work permit was issued, and the check for flammable material in the hold was superficial.15 Hot work is often carried out in connection with routine maintenance and repair operations while in port or at sea, and consequently, there may be a lack of attention and vigilance associated with the planning and carrying out of such work. The Board is concerned that the level of planning and the particular care that should be taken before hot work is carried out on board vessels may not be sufficient to ensure the safety of the work. The Board will continue to monitor occurrences involving hot work fires with a view to assessing the need for further safety action. Planning and Coordination of Emergency Plans Within Canadian ports, the responsibility for providing an emergency response plan, including firefighting assistance for vessels in port, generally rests with the port management. These plans often rely on municipal fire departments for firefighting support and on other local emergency services. Given that risks associated with an improperly coordinated response are higher than those associated with a fully coordinated response, the identification of the risks and a planned and coordinated approach are necessary to deal with a vessel-related emergency while supporting the vessel owner's efforts to deal with occurrence. In this occurrence, both the port and the city had plans and procedures in place at the time of the fire; however, the plans and procedures were neither integrated nor co-referenced. Furthermore, no specific risk analysis had been established for an emergency at the port in the city's plan. In 2001, the absence of an appropriate, current contingency plan for responding to vessel-related emergencies and the lack of emergency-related training of St. Lawrence Seaway Management Corporation personnel contributed to difficulties experienced in responding to a fire on board the bulk carrier Windoc.16 The response to a major vessel-related emergency may involve various agencies and organizations, ports and municipalities, each of which requires coordination and integration within the overall response. The Board is concerned that the continuing disparities of a planned and coordinated approach to emergencies, as demonstrated in this occurrence, will continue to jeopardize the effectiveness and the safety of the response. The Board will continue to monitor the situation with a view to assessing the need for further safety action.